Permission for verbal communications by phone, voice messaging and/or text:
The following forms provide you with information regarding your care at New Health Pain Treatment Center (NHPTC). Your initials and signature on the final page indicate that you received a copy and understand the information and agree to the terms and conditions outlined.
New Health Pain Treatment Centers offers evaluation and treatment to its patients. By signing this “Consent to Treatment” form, the patient agrees to receive the treatment included in this specific program and authorizes NHPTC, to provide medical and behavioral health services to myself. I understand that this authorization applies to all health maintenance services and to all services available for acute and chronic medical conditions and behavioral health.
The services authorized by this consent include those provided under the auspices of NHPTC by physicians, nurse practitioners, physician assistants, child health associates, medical technologists, behavioral health providers, nurses, health educators, registered nurses, medical assistants, behavioral health therapists and patient navigators. I consent to treatment by health professionals-in-training under supervision of responsible health professionals employed by NHPTC.
I understand that my medical records are to be kept confidential and will not be released to any unauthorized person or agency without my consent.
I have been provided a copy of NHPTC “Patient Rights” to review, which includes my right to make a complaint or grievance.
Therapeutic Services: NHPTC therapeutic programming meets for a scheduled amount of group time and/or individual sessions. This program is for adults seeking treatment for substance use disorders, co-occurring disorders, related behaviors and Pain Management Coping Skills. Urine drug screen testing and breathalyzer testing is a requirement upon admission and throughout treatment. The frequency of urine drug screens and breathalyzer tests are set during the course of treatment and may vary depending on therapeutic and medical necessity. Urine testing and breathalyzer testing are conducted and supervised by NHPTC staff.
I, the undersigned patient, hereby attest that I have voluntarily entered into treatment at NHPTC. The rights, risks, and benefits associated with the treatment have been explained to me and may be provided to me in writing at my request. I understand that treatment may be discontinued, and I may be discharged from the program at any time by either party. I understand that upon discharge I will receive recommendations for continuing care. Recommendations will vary depending on length of treatment program, reason for discharge and other clinical factors.
Voluntary Discharge: Patients have the right to terminate treatment prior to successfully completing NHPTC. In such cases, clinical staff will attempt to discuss the reasons for the desired discharge, possible risks associated with an early discharge and will attempt to keep the patient in treatment. The treatment team attempts to handle all early discharges in a way to minimize any harm or injuries to the patient and least disruptive to the treatment of the other patients.
Therapeutic Discharge: A non-voluntary termination/discharge may include but is not limited to: a) the need for a more appropriate level of care; b) physical violence, verbal abuse, any use or possession of weapons, engaging in illegal acts i.e.: introduces drugs or drug paraphernalia onto any of the properties of NHPTC; c) the patient refuses to comply with treatment recommendations; d) the patient does not comply with the rules, regulations, policies or guidelines of NHPTC e) the patient does not make payment or payment arrangements in a timely manner. The clinical team will notify the patient of a Therapeutic Discharge. In these cases, there will be no refund whatsoever granted to the patient for any and all monies previously received on the patient’s behalf by NHPTC.
Notice of Confidentiality: The confidentiality of patient records maintained by NHPTC is protected by Federal law as well as Colorado State law. NHPTC Staff may disclose patient information to others outside of the organization only with a Release of Information signed by the patient. Some of the information that can be disclosed with a signed Release of Information is: a) notification that the patient is at NHPTC; b) is being treated for alcohol, drugs, and/or other mental health issues/disorders and/or pain/wellness groups; c) any other identifying information such as the patient’s name; d) pertinent treatment information specific to the person outside of the organization (i.e., courts, probation, referral sources, etc.). The exceptions to this general rule of confidentiality are: 1) the disclosure is mandated by Court order: 2) the disclosure is made to medical personnel in a medical emergency; 3) the patient is a danger to self or others including those identifiable by their association with a specific location or entity; 4) the patient discloses child abuse and/or neglect; or, 5) the abuse or exploitation of an at-risk elder or the imminent risk of abuse or exploitation; 5) a crime being committed on the premises. In addition, there may be other exceptions to confidentiality as provided by HIPAA regulations and other Federal and/or Colorado laws and regulations. You will be notified should these exceptions arise. Healthcare professionals may be required under Federal law and Colorado State law to report admitted prenatal exposure to controlled substances that are potentially harmful to the unborn fetus.
Regulation and Reporting Misconduct: The Department of Regulatory Agencies (“DORA”) and the Office of Behavioral Health (“OBH”) regulate the mental health professionals and staff at NHPTC. Colorado Department of Regulatory Agencies (DORA), Division of Professions and Occupations (“DOPO”) has the general responsibility of regulating the practice of Licensed Psychologists, Licensed Clinical Social Workers, Licensed Professional Counselors, Licensed Marriage and Family Therapists, Certified and Licensed Addiction Counselors and Registered individuals who practice psychotherapy. The agency within DORA that specifically has responsibility is the:
Specifically, the State Board of Addiction Counselor Examiners regulates Certified and Licensed Addiction Counselors, the State Board of Licensed Professional Counselor Examiners regulates Licensed Professional Counselors, and the State Board of Registered Psychotherapists regulates Registered Psychotherapists and can be reached at the address listed above. Patients are encouraged, but not required, to resolve any grievances through NHPTC internal process. Otherwise, patients should report all alleged misconduct to the above listed state Board. The specific Board should be specified in the report.
In addition, the Office of Behavioral Health has the general responsibility for regulating practices of licensed substance use treatment programs in the state of Colorado. Questions and Complaints may be directed to:
In the event of death of the patient and under certain circumstances, it may be the right of the Spouse and/or Parents and/or Children to access the records of the deceased patient. This right is not guaranteed.
Amendments: This Consent to Treatment may be amended in writing from time to time and signed by both parties.
Contact Method: NHS uses a variety of ways to contact patients related to their care such as phone, text and/or email about their healthcare, to include visit information, reminders, account balance notifications and other services. Patient has the right to select to be contacted by phone, text and/or email during and upon discharge from the program. Please be aware there is a risk that an unintended third-party may access information shared through electronic transmissions such as email and/or text. By allowing NHPTC to contact you by email you are consenting to receive electronic communications and understand the risks involved. NHPTC cannot guarantee that confidential information shared using electronic communications will remain confidential. If select to be contacted by telephone I give my permission to NHPTC to leave phone messages and to identify themselves either by staff name and/or by the program name. I understand that message and data rates may apply to messages sent through NHS to my cell phone or email. I know that I am under no obligation to authorize NHS to send me text messages or emails as part of this program. If at any time, a patient wishes to revoke any authorization it will be done in writing notifying NHS and specified the type of contact method no longer valid.
I have read and understand the consent for treatment. I understand its content and do voluntarily agree to its provisions. This authorization is applicable for the period of one year, effective upon signing.
The following is a statement of rights and responsibilities of all New Health Pain Treatment Center patients:
Patients have the right to:
Patients have a responsibility to:
Our Uses and Disclosures: We may share your information as we:
You have the right to:
You have some choices in the way that we use and share information as we:
Our Uses and Disclosures
We may use and share your information as we:
When it comes to your health information, you have certain rights.This section explains your rights and some of our responsibilities to help you.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
How do we typically use or share your health information?We typically use or share your health information in the following ways.
How else can we use or share your health information?We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
We would like to thank you for choosing New Health Pain Treatment Center (NHPTC) as your healthcare provider. NHPTC is committed to providing you with the best possible care. We are sure you understand that payment for this healthcare is your responsibility. The following information outlines your financial responsibilities related to payment for professional and behavioral health services. No one is denied services because of the inability to pay.
Payment is expected at time of service. For your convenience we accept cash, checks or the following credit cards: Visa, MasterCard, American Express and Discover.
For Our Patients with Medical Insurance: Please bring your insurance card with you at the time of your appointment and it is the patient’s responsibility to provide all necessary information before leaving the office.
NHPTC will submit claims for any services rendered to a patient for the insurance plan that we participate with to get your claims paid. If you have a secondary insurance we will automatically file a claim with them as soon as the primary carrier has paid. Your insurance company may need you to supply certain information directly and it is your responsibility to comply with their request.
If you are insured by a plan we do business with but don't have an insurance card with you, payment in full for each visit is required until we can verify your coverage.
If a patient is a member of an insurance plan with which we do not participate, payment in full is due at the time of service.
Additionally, you may have coinsurance and/or deductible amounts required by your insurance carrier. Any outstanding balance on your account, after adjusting for all of your insurance's responsibilities, will be billed to you.
Medical services that are considered by your insurance company to be non-covered, out of network, or not medically necessary will be your responsibility.
If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.
Payment Plan: Please let us know if you are having difficulty paying your account. We may be able to help you by setting up a payment plan based on your financial hardship, call (720) 274-0341.
Returned Checks: If your check is returned to us for either insufficient fund, you will be assessed a $25.00 fee on top of your copay or balance due. Personal checks will no longer be accepted by you for payment.
Account Balances: Monthly statements will be mailed to you for outstanding balances on your account.
Collections and Bad Debt: If you are repeatedly delinquent on either account balance, your bad debt will be sent to a collection agency.
Assignment of Benefits: I request payment of insurance benefits to NHPTC. I understand that I am financially responsible for all copays and charges not covered by insurance. I hereby authorize the release of any medical information necessary to process all claims.
Cancellation and No-Show Appointments: We understand that situations arise in which you must cancel your appointment. It is therefore requested that if you must cancel your appointment you provide more than 24 hours’ notice. This will enable for another person who is waiting for an appointment to be scheduled in that appointment slot. With cancellations made less than 24 hours’ notice, we are unable to offer that slot to other people. Office appointments which are cancelled, rescheduled and/or no show with less than 24 hours’ notification will be subject to a $50.00 cancellation fee. Due to contractual obligations with Medicare and Health First Colorado (Medicaid) the $50 fee does not apply.
If you arrive more than 15 minutes past your scheduled appointment time we may have to reschedule your appointment and you will be charged a $50 reschedule fee.
NHPTC firmly believes that good physician/patient relationship is based upon understanding and good communication. Questions about cancellation and no-show fees should be directed to the Billing Department (720) 274-0341.
I have read the Financial Policy and I understand and agree with this Financial Policy.
The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed psychotherapists and unlicensed psychotherapists. New Health Pain Treatment Center (NHPTC) therapeutic staff consists of licensed psychotherapists, certified psychotherapists, therapists eligible for licensure and/or unlicensed therapists receiving clinical supervision by a licensed clinician. The agency within the department that has a responsibility specifically for licensed and unlicensed psychotherapists is:
The Division of Registrations1560 Broadway, Suite 1350Denver, Colorado, 80202303.894.7800
In the State of Colorado, the agency responsible for overseeing and regulating practices of licensed substance use disorder treatment programs is:
The Colorado Department of Human ServicesOffice of Behavioral Health3824 W. Princeton Circle, Denver Colorado, 80236(303) 866-7400
The regulatory requirements applicable to mental health professionals are as follows:
Client Rights and Responsibilities: You are entitled to receive information about NHPTC clinicians and about the methods of therapy, techniques used, and duration of therapy and fee structure. You can seek a second opinion from another therapist or terminate therapy at any time. In a professional relationship (such as ours) sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the State Grievance Board.
Generally speaking, the information provided by and to a client during therapy sessions is legally confidential and the therapist cannot be forced to disclose this information without the client's consent. There are exceptions to the general rule of legal confidentiality. These exceptions are listed in the Colorado -Statutes Section 12-43-218, CRS, as well as other exceptions in Colorado and Federal Law such as the Federal Confidentiality Regulation, 42 C.F.R. Part 2. Some of the situations in which we release information without your consent are:
If you have any questions or would like additional information, please ask NHPTC staff. The clinical staff employed at NHPTC and their qualifications/credentials are as follows:
Osvaldo Cabral, LPC, LAC Director of Integrated ServicesM.A., Clinical Psychology, University of ColoradoLicensed Professional Counselor #6099Licensed Addictions Counselor #0631Dialectical Behavior Therapy Intensive
Maria Vicky Buethe, BA, CAC IIB.A., PsychologyRegistered Psychotherapist #0107166Certified Addictions Counselor #7558
Elizabeth Golias, MA, LPCCM.A. Counseling PsychologyUniversity of DenverLicensed Professional Counselor Candidate #0016719
The following organizations/providers are hereby authorized to release, exchange and share my protected health information (PHI) with New Health Services, LLC, New Health Pain Treatment Centers and Englewood Surgery Centers:
I understand that the information in my health record may include information relating to sexually transmitted disease (STD), acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental services, and treatment of alcohol or drug abuse.
State and federal law protects the following information. If this information applies to you, please indicate if you would like this information released/obtained (include dates where appropriate):
By signing this authorization form, I understand that:
Request for copies of medical records are fees in accordance with federal/state regulations.
I have the right to revoke this authorization at any time. Revocation must be made in writing and presented to the Office Manager at the following address: 3277 S Lincoln Street, Englewood, CO 80113.
Unless otherwise revoked, this authorization with expire on the following date/event/condition: If I fail to specify an expiration date/event/condition, this authorization will expire one (1) year from the date signed.
Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization.
Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information my not be protected by federal confidentiality rules.
Prescription opioid and controlled substance medications may be used in certain cases for the treatment of chronic pain, however they present serious risks to patients and others. We expect patients to use these medications safely and responsibly if your provider believes it is an appropriate part of your treatment plan at New Health. Ultimately, prescriptions for opioid and controlled substance medications are YOUR responsibility.
1. It is my responsibility to make sure I have an appointment scheduled in clinic with my provider with sufficient time allowed to ensure timely refill of prescriptions. Medications will only be prescribed IN PERSON, and should be refilled at a dedicated appointment close to the date a refill is due. Medications WILL NOT be prescribed without an in-person clinic visit, or refilled after hours or on weekends. I WILL bring all medications prescribed by my provider to every visit, and agree to present to the clinic within 24 hours for random pill counts when requested.
2. I will obtain all prescriptions from the SAME PHARMACY. Should the need arise to change pharmacies, I will inform my provider.
3. I WILL take my medications exactly as prescribed. If I believe that my medication dose or frequency is not enough, I agree to schedule a visit in clinic with my provider to discuss any desired changes in person. I understand that if I use more medication than prescribed or run out of medications early, my provider may decide not to refill my medication early and/or not continue to prescribe opioid or controlled substance medications.
4. I UNDERSTAND that if anything happens to my medications, for example they are lost, stolen, or accidently destroyed, my provider may decide that it is NOT appropriate to rewrite my prescription and/or may not refill the prescription until the designated refill date.
5. I UNDERSTAND that my provider will determine the appropriate interval for me to receive prescriptions for opioid or controlled substance medications, for example weekly, every other week, monthly, etc.
6. I WILL NOT receive prescriptions for opioid or controlled substance medications from any other person without explicit permission from my provider at New Health.
7. I WILL communicate to every other medical professional I receive care from that I am receiving prescriptions for opioid or controlled substance medications from my provider at New Health. I understand that my provider has permission to discuss details of my treatment with other medical professionals involved in my care, including pharmacists. I WILL agree to sign any Release of Information forms requested by my provider.
8. I WILL consent to random toxicology testing by providing unadulterated samples of my urine, saliva, and/or blood upon request by my provider. I WILL NOT use any illegal drugs or substances or use any controlled substances which are not prescribed by my provider, including marijuana/cannabis/THC. If I refuse to provide a toxicology sample when requested, I understand that my provider may not prescribe opioid or controlled substance medications.
9. I UNDERSTAND that New Health uses a multidisciplinary approach and visits with the Behavioral Health team will be recommended by my provider and the behavioral health staff. This may include weekly, biweekly, or monthly therapy groups and/or individual therapy sessions. I WILL participate, in a timely manner, in all treatment recommendations and referrals as determined by my providers at New Health. This may include physical therapy and imaging such as x-rays or MRIs.
10. I WILL show up to my scheduled appointments with sufficient time to complete any necessary paperwork or questionnaires BEFORE the scheduled time of my appointment, 30 minutes before my initial visit and 15 minutes before every follow-up visit.
11. I UNDERSTAND that prescription opioid and controlled substance medications can lead to impairment of thought processes, especially if I combine these medications with other sedating medications or substances, for example sleeping pills, tranquilizers, alcohol, kratom, and marijuana/cannabis/THC. I WILL NOT consume alcohol or marijuana/cannabis/THC while receiving prescription opioid and controlled substance medications.
12. I UNDERSTAND that chronic use of prescription opioid and controlled substance medications comes with risks of the following potential side effects:
13. I UNDERSTAND that if I am pregnant or plan to become pregnant, I must inform my provider immediately and that they may decide that it is in the best interest of myself and my baby to safely wean me off my prescription opioid or controlled substance medications.
14. I WILL inform my provider at New Health in a timely manner of any new medications I am prescribed or medical conditions I am diagnosed with, as well as any side effects I experience from taking any of the medications I am prescribed.
15. I UNDERSTAND that changing my prescription in any way, including changing the date, quantity, or strength of medication, and/or forging the signature is against the law. Violations will be reported to my pharmacy, local authorities, and Federal Drug Enforcement Agency for prosecution.
16. I UNDERSTAND that it is my responsibility to keep others and myself safe from harm. If I or my provider believes that my medications prevent me from driving or operating machinery safely, I will refrain from doing these activities.
17. I UNDERSTAND that prescription narcotic and controlled substance medications will be stopped if I violate any of the requirements above, or if I do any of the following:
What are Advanced Directives?
"Advanced Directives" are legal documents where you explain and plan your end-of-life wishes in the event that something happens and you cannot communicate. Advanced Directives consist of:
A living will describes what you want regarding medical care and a medical power of attorney is a person you've identified to be the point person to make healthcare decisions for you in case you cannot communicate.
If you have any questions about Advanced Directives, please speak with your provider and/or behavioral health therapist.
It is the policy of New Health Services program to maintain a plan of action for medical emergencies, fire, disaster and causalities in accordance with OBH Code of Regulation 21.290.41. The policy includes:
In case of medical emergencies staff and patients are to call EMS services provided by the city by contacting the emergency medical services (911). Refer to Emergency Call List for contacting pertinent staff. Director(s), medical and behavioral health staff will educate/inform patients post emergencies. Patients will also sign this policy as part of the intake packet.
NHS program will hold quarterly safety and fire drills incorporating the designation of proper authority amongst staff with their assignments in case of disaster or causality. Fire and safety drills will be held at unexpected times and under varying conditions. At least 50% of the drills will be unannounced. A staff discussion will be held at the following staff meeting to critique the drill and strengthen safety plans. Plan of evacuation will be provided to all staff upon employment and to patients upon acceptance of treatment within the program. Planned evacuation exit strategies are posted throughout the facility in a visible place.
Plan of Evacuation
In case of evacuation, patients and staff will walk out of the front door and across Lincoln Street and wait in the dirt parking lot east of the building for fire trucks and/or other emergency responders. To ensure building has been evacuated, designated staff will check each room for vacancy. Place trash can outside of closed door to identify empty rooms. If the front door is not accessible, patients and staff will walk out of the side door and/or the ESC door as designated by staff. All staff and patients will remain as a group, at minimum, 100 feet from the building to wait for fire trucks or other emergency responders. If exits at both doors are blocked, patients and staff will exit out of a safest open window in a room, office or community area and meet in the parking lot located across Lincoln St.
Supervision of Patients
Supervision of patients after evacuation and relocation will be provided by the clinical and administrative staff available following direct instructions from the Director(s).
Transportation of Patients
Transportation of patients is unnecessary unless medical emergency warrants such evacuation of patients or staff. In these cases, 911 will be called for transportation of patients and/or staff.
Patient Education in Response to Fire
After a fire, patients will be contacted by phone from an NHS staff member and given an update on damage to the building and plan to begin treatment again. An immediate debriefing group will be arranged either at the facility when possible or another designated location. The location will be pre-determined by the Director(s) prior to the patient phone call. Patients will have an opportunity to discuss the fire, any damage to the building and the emotional and physical effect they experienced. Other discussion points will include:
Personnel Education and Actions Regarding Medical Emergencies and Arrangements
New Health Services will hold quarterly in-house trainings on the NHS Medical Emergency and Fire procedures. Discussions will include results from the quarterly safety and fire drills and review of any changes in policy and procedure.
Cardiac and/or Respiratory Arrest
All staff are trained in First Aid and Basic Life Support (BLS) Services. In cases of cardiac and/or respiratory arrest staff will initiate First Aid and/or BLS and ensure a phone call is placed to 911 Emergency Medical Services (EMS). Once EMS staff arrive on scene the person in cardiac and/or respiratory arrest will be placed in their care and transferred to the appropriate facility. Staff will document the incident in a Critical Incident Report and notify the Director(s) immediately.
In the case of a tornado, hail storm, flash flood warnings, and blizzard conditions, patients and employees to remain in the interior of the building, away from all doors and windows. In the ESC, interior meeting area would be the PACU. On the NHS clinic side, the interior corridor near BH offices will be the meeting area.
Acts of Terrorism
If an active shooter, threat, or violent patient appears in the front waiting room, front office to push panic button underneath the east side of the front desk. The panic button if held for 3 seconds will automatically summon police. As situation allows, staff are notified via slack to stay in rooms or come to front for support.
In order to provide you with the best possible care, we occasionally send convenient text messages to our patients about their health care, account balances and services we offer.
By signing below, I authorize New Health through its vendor eClinicalWorks to contact me by SMS text message to serve me better. New Health will send me text messages to help with the following:
I understand that message/data rates may apply to messages sent through New Health to my cell phone.
I know that I am under no obligation to authorize New Health to send me text messages as part of this program.
I may opt-out of receiving these communications from New Health at any time by calling New Health @ (720) 274-0341.